169 Unsuccessful submandibular duct surgery for anterior drooling: Surgical failure or parotid gland salivation? 8 INTRODUCTION Anterior drooling is the continuous visible spillage of saliva.1 Although Crysdale et al2 stated that drooling must be considered abnormal after the age of 4 years, a substantial part (3-15%) of the typically developing preschoolers are still drooling to a certain extent at 4 years of age. Not all these children probably suffer from pathological drooling, but drooling within a small group of children is within the range of normal variability.3 Drooling is not caused by hypersalivation.4 Rather, drooling is caused by a combination of several factors like diminished awareness to swallow, poor posture and dysfunctional oral motor functions (decreased perioral sensitivity, diminished swallow frequency, disturbed muscle tone, problems with the coordination of swallowing).4-6 The submandibular gland produces the vast majority of saliva (65-70%) at rest, it comprises serous and mucous cells (the latter the most active). The largest salivary gland, the parotid gland, is mainly active following gustatory stimulation. It is responsible for 20% of total saliva in rest, but when stimulated this rises to over 50%. The parotid glands consist mainly of serous acinary cells.7 Surgical treatment is usually postponed until a later age to await a child’s development.8 Non-surgical therapeutic modalities include; speech therapy, behavioral therapy9,10, anticholinergic drugs11 and intraglandular botulinum toxin injections12,13. These therapies often bridge the gap towards surgical treatment.14 As the submandibular glands produce the vast majority of saliva during rest, the primary focus for surgical intervention is on the submandibular glands.15,16 Over the years bilateral submandibular duct relocation (SMDR) with or without excision of the sublingual glands has arisen as the de-facto standard surgical technique.14,16,17 Since neurologically disabled children commonly have a dysfunctional oral phase of swallowing, relocation of the submandibular ducts to the oropharynx will enhance the swallowing of saliva . When children suffer from aspiration of saliva (posterior drooling), a combined oropharyngeal swallowing disorder, or a progressive underlying neurological condition this procedure is
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